Analyse the case and answer the following s; 1.Which of the.
Analyse the case and answer the following s; 1.Which of the… Analyse the case and answer the following s;1.Which of the above NMBA Guidelines have been breached by the nurse and how?Enrolled Nurse competency standards for practiceProfessional boundariesProfessional practice guidelinesDecision-making framework (DMF) including the nursing flowchartRe-entry to practiceRegistration guidelinesRecency of practiceCode of EthicsCode of Conduct2. Who, in the case, is responsible for the Mandatory Reporting?3. Which of the following Ethical Principals were amiss in each case and why? Autonomy, beneficence, non-maleficence, confidentiality, justice, rights and veracity.4. What current Commonwealth and State/Territory legislation relate to the issues within each case?5. If the EN inhad followed their duty of care, do you think the outcome of their case would have changed?6. If the EN inhad followed the principals of open disclosure, do you think the outcome of their case would have changed?7. Which of the following could have impacted on the case if there had/was one in place and why: power of attorney, living will and advanced directives.8. Which of The National Safety and Quality Health Service Standards (NSQHS Standards), have not been adhered to in each case? What was the impact?9. Were there any human rights/access to healthcare that were violated in these cases?10. Give a brief reflection on your thoughts of each case and how you can relate what you have learnt into to your practice.CASE:Inquest into the death of Ms Shelley YoungMs Shelly Young was a 65 year old woman who died at ManlyHospital, Sydney on 29 September 2007. She died from choking on atangerine. She had been identified as a choking risk and as needing tobe supervised while she ate. She obtained the tangerine from a fruitbowl that was left out for patients. Admission to Manly Hospital:-Ms Young was seen in the emergency department on 20 September2017 and was ultimately admitted to Medical Ward 1 with aprovisional diagnosis of delirium, potentially due to cellulitis or aurinary tract infection. Because she required treatment for herphysical illness but also needed ongoing psychiatric care, Ms Youngwas referred to the consultation liaison psychiatry team, a servicecatering for the mental health assessment and treatment of patientsadmitted to the medical and surgical wards of the hospital. Ms Youngregularly saw Dr Anna Bolliger, Staff Specialist Psychiatrist during heradmission and Dr Bolliger also had several discussions with Dr Alle (MsYoung’s community psychiatrist), with Ms McGregor and with theadmitting physician and treating team managing Ms Young’s othermedical care on Medical Ward 1.-Various pro re nata (PRN) medications were administered to MsYoung across the course of this admission, in addition to the routinemedications she was taking at the time of her admission.- In addition, at the time of admission Manly Hospital received andincluded within their records, various documents from RSL Tobrukwhich in turn included some material that had been provided byMacquarie Hospital. This material included reference to Ms Youngbeing at risk of choking because of, amongst other things, her lack ofteeth, a swallowing/chewing disorder, reduced mastication andimpulsivity.- A swallow assessment conducted on 18 September 2017 whilst MsYoung was at RSL Tobruk, led to recommendations noted in therecords available to Manly Hospital, that Ms Young be fully supervisedat all time during meals and a soft moist food diet be trialled.- Ms Young was supervised with her meals whilst a patient on MedicalWard 1 and arrangements were made for Ms Young to be furtherassessed via a formal speech review. The speech review did not,however, occur.- Ms Young was ultimately transferred to the Specialist Mental HealthWard for Older Persons at Manly Hospital on 28 September 2017. Shewas placed on Level 2 observations, requiring observation every 15minutes.On 29 September 2017 Ms Young spent some time with MsMcGregor.- On the same day Nurse Unit Manager (NUM) Muriithi contacted theregistrar on the treating team and requested a medical reviewbecause she was concerned Ms Young might still be experiencingdelirium. Ms Young was reported to be agitated, walking around theward and knocking on windows. Ms Young was assessed by a JuniorMedical Officer who recorded the impression of resolving delirium ona background of manic relapse of schizoaffective disorder.- At some time around 1pm Ms Young was given 1 mg Haloperidol (anantipsychotic) with some effect.- According to the nursing observation charts Ms Young was observedin the corridor at 1300 and 1315 and was back in her room at 1330and 1345. The observation at 1400 had Ms Young in her room andcourtyard, perhaps she was walking between the two. At 1415 MsYoung was seen in the corridor.- At 1430 NUM Muriithi carried out a walk-thru of the ward anddiscovered Ms Young in her room, slumped in a chair. She wasunresponsive. According to NUM Muriithi, when she discovered MsYoung, she was seated peacefully and the witness’ first impressionwas that Ms Young had experienced a cardiac arrest.- NUM Muriithi called for help, a call for the rapid response team wasmade and CPR attempts continued until about 1535 that afternoon. During resuscitation and on direct laryngoscopy 4-5 pieces oftangerine were seen in Ms Young’s airway and removed.Resuscitation was unsuccessful.- At the request of Ms McGregor a limited autopsy was conducted,limited to external examination and toxicology. The forensicpathologist concluded that the cause of death was choking.- The forensic pathologist informed this court that it is not uncommonfor first responders not to be able to see obstructing food boluses inthe airways, food could be too deep into airways and also the tonguecan obstruct their vision. She said that the possibility that thetangerine originated from the stomach (in the course of CPR) cannotbe completely excluded however, based upon the medical recordsthat tangerine pieces were removed, that there was the absence ofupper teeth and limited lower teeth, past choking episodes,documented choking risks, documented delirium and confusion,eating without supervision and not eating soft foods, she determinedthe cause of death as in keeping with choking- On balance, for the reasons set out by the forensic pathologist I amsatisfied that the cause of Ms Young’s death was choking. The adequacy of steps taken to assess Ms Young’s ability to swallow and supervise mealsduring the admission to Manly Hospital:- By the 1990s Ms Young had lost all but two of her teeth.- Ms McGregor reports that in 2009 Ms Young was taken to RydeHospital from Macquarie Hospital with a piece of apple lodged in herthroat.- On 16 March 2016 an “alert” was entered in the LHD EMR recordingMs Young “choked on food”.- The discharge summary from Macquarie Hospital on 18 July 2017 asprovided to RSL Tobruk identifies Ms Young’s choking risk. This alsonoted that Ms Young had returned to a full diet at the request of MsMcGregor, despite the identified choking risk.-Further problems were observed at RSL Tobruk. On 17 September2017 Ms Young choked on her food at lunch prompting a speechpathology assessment the next day.- Ms Young then choked on a small piece of biscuit at Tobruk on 19September 2017.- There were several contributing causes: lack of teeth, tardivedyskinesia (abnormal tongue movement likely due to the use of firstgeneration anti psychotics in particular), dysphagia (impairedswallowing associated with multiple complications of anti-psychoticuse including impaired function of the musculature of the mouth,pharynx and oesophagus), and behaviourally, Ms Young’s tendency at times to eat and talk at the same time.- Manly Hospital were on notice of these problems with choking. Therecords provided by RSL Tobruk included the speech pathologyassessment of 18 September 2017 which said, amongst other things,”Other directives” Swallow AX 18/09/17 Ms Young presents with mildpredominately oral phase dysphagia on b/g of missing dentition andcognitive issues associated with a mental health background. Due tolimited food trials today unable to ascertain extent of dysphagia andimpact missing dentition has on her mastication ability, howevergiven recent change in behaviour ?infection and recent chokingepisode, she is to commence a soft moist diet with hard meats cutfinely and thin fluids in isolation. Softer meat alternatives such asflake fish are appropriate. Please ensure she is FULLY SUPERVISED atall times during meals and please ensure staff are reminding her notto speak while eating. Sister Ms McGregor called and updated onrecommendations and outcome of ax. Recommendations: 1 softmoist diet with all meats cut finely. Softer alternative provided ifavailable (flake fish and mix with sauce or soft processed ham) ALLFOOD CUT FINELY 2. Ideally avoid all hard, dry, particulate, stringy,gristly or mixed consistency foods. No bread or toast please untilfurther ax can be conducted. 3. Extra sauce to help keep moist and toadd flavour, 4. Thin fluids ideally in is olation 6. No dual consistencies7. Medications as tolerated 8. FULL set up assistance 9. FULLsupervision with intake 10. To be 90 degrees upright with neckfixation during and 30 mins post all intake 11. Rigorous oral care postintake 12. Small mouthfuls at a slow pace encouraged (requiresprompting) 13. r/v 1/52 to check tolerance and adherence to regime.Please contact SP immediately if signs of aspiration (coughing, choking, throat clearing, wet voice) observed on current regime, ifchest declines or she is unable to swallow- Ms Young had been transferred to Manly Hospital by the time herfollow up speech pathology review was due at RSL Tobruk.- Dr Alle specifically raised this issue with Dr Bolliger who discussed itwith NUM on Medical Ward 1, Genevieve McKinnon. NUM McKinnonrecalled a discussion around Ms Young impulsively gulping food orwater, something she had observed for herself. She further told theCourt that Ms Young’s swallowing risk was also an alert in thePowerchart system which was the hospital electronic medical recordssystem.- NUM McKinnon further noted that Ms Young was getting meals underthe ‘blue mat/red mat’ system. Because Ms Young was classified asbeing ‘red mat’ that meant staff were alerted to the fact that themeals were not to be delivered to Ms Young in person but rather onlya nurse could take a meal into her. In addition, Ms Young was being’specialled’ 1 to 1 during her time on Medical Ward 1.- The treating doctors on Medical Ward 1 were alerted to the risk. Anentry in the EMR for Saturday 23 September 2017 referred to amedical review by Dr Sanela Redzepagic saying nurses observed MsYoung to eat well – no coughing or difficulty with food but that sheshould have a formal speech pathology review on Monday (25September 2017). No speech pathology review followed. -The London Protocol Report, dated 11 December 2017, observed”despite the alerts to choking risk, and extensive documentation inthe consumers’ EMR file regarding speech assessment findings andrecommendations of a soft diet, there was no nursing notes on themedical ward apart from two references to diabetic diet that wasinitiated on 21 September 2017″- The handover from Medical Ward 1 to the Specialist Mental HealthWard for Older Persons, including details of the increased risk ofchoking, was patently inadequate.- The London Protocol Report stated as follows “Nursing/clinicalhandover from medical to older persons mental health unit did notinclude speech/diet alerts nor history of two prior choking incidentson the 18/09/17 and 19/09/17 nor care planning to ensure riskmitigation. The older persons mental health unit inpatient admissionchecklist has a prompt for diet but not for speech assessment. An RNdid make a referral for speech assessment on 29/09/17 at the sametime as referring five other patients however this was no recorded inthe consumer’s EMR file.”- This omission at handover meant that no arrangements were in placeon the Older Persons Mental Health Unit to monitor Ms Young atmealtimes or when eating.- This was particularly important as Ms Young was in all probability stillexperiencing delirium at the time of her transfer to the second ward.Symptoms of delirium can fluctuate over time, including fluctuatingacross any given day and so observations of delirium resolving are not reliable in isolation. Associate Professor Wijeratne emphasised thatdelirium can be quite prolonged and was previously prolonged for MsYoung during the RNSH admission.- Furthermore, NUM Muriithi on the day that Ms Young died,requested a medical review because she was concerned that MsYoung was still experiencing some delirium.7 Upon review Ms Youngwas reported to be disoriented, emotionally labile and exhibitingsome psychiatric phenomenology. Continuing supervision of eatingwas all the more important in that circumstance- There was a fruit bowl on the Specialist Mental Health Ward.- The inappropriateness of that fruit bowl, as arose in the case of MsYoung, was that fruit was available to those who should have beensupervised whilst eating but who lacked the capacity to remember towait until supervised before helping themselves to a piece of fruit. Health Science Science Nursing NURSING 55
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